Days with and without self-injurious thoughts and behaviors: Impact of childhood maltreatment on adolescent online social networking.

INTRODUCTION: Among adolescents, an increasing rate of interpersonal interactions occurs online. Previous research has shown that interpersonal context exerts a robust impact on suicidal thoughts or behaviors, yet little attention has focused on examining the content of online interactions surrounding self-injurious thoughts or behaviors. As such, the present study sought to compare online social networking behaviors among adolescents on days with and without experiencing self-injurious thoughts or behaviors, as influenced by childhood maltreatment history. METHOD: Adolescents aged 13-18 hospitalized for self-injurious thoughts or behaviors were recruited as part of an ongoing longitudinal study. A subsample (N = 22) of adolescents provided data from their online social networking platforms (i.e., text messages, Facebook, Instagram, and Twitter). Using a mixed-methods approach, online social networking data on days of experiencing self-injurious thoughts or behaviors and days of not experiencing self-injurious thoughts or behaviors were compared. RESULTS: Results indicate the frequency and content of online social networking messaging do not change by day of self-injurious thoughts or behaviors or history of childhood maltreatment. However, childhood maltreatment predicts received conflictual messages as well as sent symptomatic messages on days of experiencing self-injurious thoughts or behaviors. CONCLUSIONS: Childhood maltreatment may play a role in the content of adolescent online behaviors, particularly on days when they experience self-injurious thoughts or behaviors. Implications for intervention are discussed.

Dialectical behavior therapy for adolescents (DBT-A): Outcomes among sexual minorities at high risk for suicide.

The alarming rates and pervasiveness of suicidal and self-destructive behaviors (e.g., non-suicidal self-injury) among young sexual minorities represent a major public health concern. We set out to examine whether an empirically driven treatment for suicide and self-harm, dialectical behavior therapy for adolescents (DBT-A), provides benefits for adolescents who identify as gay, lesbian, bisexual, or questioning (LGBQ). LGBQ adolescents (n = 16) were compared with non-LGBQ peers (n = 23). Psychological measures were collected before and after participation in a comprehensive DBT-A program. LGBQ participants demonstrated significant improvements in emotion regulation, depression, borderline symptoms, and coping strategies; changes were comparable to their heterosexual peers.

Do styles of emotion dysregulation differentiate adolescents engaging in non-suicidal self-injury from those attempting suicide?

Emotion dysregulation is implicated in both suicide attempts (SA) and non-suicidal self-injury (NSSI). However, little is known about how emotion dysregulation may differ between adolescents who have made an SA from those engaged in NSSI. We sought to address this gap by comparing emotion dysregulation profiles across three homogenous groups of adolescents (1) SA-only (2) NSSI-only (3) and typically developing controls (TDCs). Mean comparisons suggest that adolescents with a history of NSSI reported significantly lower distress tolerance and higher emotional reactivity when compared to adolescents who made an SA. After controlling for shared variance across emotion dysregulation measures, parent report of affective lability was the only scale to uniquely distinguish between NSSI and SA groups. Accurately distinguishing emotion dysregulation patterns across self-injurious groups has practical implications towards assessment, treatment, course of illness, and prevention.

Identifying personality pathology associated with major depressive episodes: incremental validity of informant reports.

Major limitations are associated with the use of a single source of information to assess personality pathology. The construct validity of standardized interviews and informant reports on personality pathology has been established relative to other measures of personality pathology, but it is also important to consider these measures in relation to other constructs that should be related to personality pathology. One example is major depression. In this study, we evaluated whether less common clinical methods of assessment for measuring the same personality pathology constructs, including semistructured interviews and informant reports, demonstrate unique validity, using major depressive episode (MDE) as the external criterion. This analysis focuses on a representative, community-based sample of 1,437 participants and informants. We conducted a hierarchical logistic regression analysis and determined the order of entering the predictor variables based on likelihood of being used in a clinical setting as well as empirical recommendations. Each step of our regression model significantly increased our ability to predict lifetime MDE, including self, interviewer, and informant reports of personality pathology. Overall, these findings indicate that multiple sources of personality assessment provide unique information about the relationship between maladaptive personality traits and a history of MDE. Thus, semistructured diagnostic interviews and informant reports can be used as a resource to improve the validity of personality assessments.

The relationship between borderline personality disorder and major depression in later life: acute versus temperamental symptoms.

OBJECTIVE: A recent issue in the personality disorder field is the prevalence and course of Axis II symptoms in later life. Focusing on the presentation of personality disorder criteria over time may have some utility in exploring the relationship between borderline personality disorder (BPD) and major depression in older adults. Temperamental personality symptoms are relatively resistant to change but tend to be nonspecific to disorders, whereas acute symptoms remit relatively quickly. We predicted that temperamental BPD symptoms would be positively correlated with a history of depression and did not expect to find a relationship between major depression and acute BPD symptoms. METHODS: A total of 1,630 participants between the ages of 55 and 64 were recruited to participate in a community-based longitudinal study representative of the St. Louis area. Participants completed a battery of assessments at baseline, including diagnostic interviews for all 10 personality disorders and major depressive disorder. RESULTS: Temperamental and acute BPD symptoms were significantly correlated with a history of major depression. After adjustments were made for the effects of temperamental symptoms on depression, acute symptoms were no longer correlated with a history of depression. As predicted, temperamental symptoms remained significantly related to depression, even after controlling for the effects of acute symptoms. BPD acute symptoms showed a unique negative correlation with the amount of time following remission from a depressive episode. CONCLUSIONS: Overall, this study supports associations between major depression and borderline personality in older adults. The findings indicate that a history of major depression is primarily related to stable BPD symptoms related to emotional distress, which are more prevalent in older adults than acute features.

Does the diagnosis of multiple Axis II disorders have clinical significance?

BACKGROUND: A stated goal of the DSM-5 Work Group on Personality and Personality Disorders (PDs) has been to reduce the high rate of comorbidity among PDs. Few studies have examined whether the diagnosis of multiple PDs has clinical significance. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we tested the hypothesis that patients with >1 DSM-IV PD would have more severe forms of psychopathology than patients who were diagnosed with only 1 DSM-IV PD. METHODS: A total of 2,150 psychiatric outpatients were evaluated with semi-structured diagnostic interviews for DSM-IV Axis I and Axis II disorders and measures of psychosocial morbidity. RESULTS: For 8 of the 10 PDs, the majority of patients had at least 1 additional PD, although at least 20% of patients diagnosed with each PD were diagnosed with only 1 PD. Compared with patients with 1 PD, patients with ≥2 PDs had significantly more psychosocial morbidity. CONCLUSIONS: The co-occurrence of PDs conveys clinically significant information. Moreover, despite high levels of comorbidity, each PD also existed as a stand-alone entity. These findings raise questions about the DSM-5 Work Group's emphasis on reducing comorbidity in Axis II.

Overcoming the problem of diagnostic heterogeneity in applying measurement-based care in clinical practice: the concept of psychiatric vital signs.

Measurement-based care refers to the use of standardized scales to measure the outcome of psychiatric treatment. Diagnostic heterogeneity poses a challenge toward the adoption of a measurement-based care approach toward outcome evaluation in clinical practice. In the present article, we propose adopting the concept of psychiatric vital signs to facilitate measurement-based care. Medical vital signs are measures of basic physiologic functions that are routinely determined in medical settings. Vital signs are often a primary outcome measure, and they are also often adjunctive measurements. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we examined the frequency of depression and anxiety in a diagnostically heterogeneous group of psychiatric outpatients to determine the appropriateness of considering their measurement as psychiatric vital signs. Three thousand psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM-IV supplemented with items from the Schedule for Affective Disorders and Schizophrenia. We determined the frequency of depression and anxiety evaluated according to the Schedule for Affective Disorders and Schizophrenia items. In the entire sample of 3000 patients, 79.3% (n = 2378) reported clinically significant depression of at least mild severity, 64.4% (n = 1932) reported anxiety of at least mild severity, and 87.4% (n = 2621) reported either anxiety or depression. In all 10 diagnostic categories examined, most patients had clinically significant anxiety or depression of at least mild severity. These findings support the routine assessment of anxiety and depression in clinical practice because almost all patients will have these problems as part of their initial presentation. Even for those patients without depression or anxiety, the case could be made that the measurement of depression and anxiety is relevant and analogous to measuring certain physiologic parameters in medical practice such as blood pressure and body temperature regardless of the reason for the visit.

Screening for bipolar disorder with the Mood Disorders Questionnaire: a review.

BACKGROUND: Several research reports have suggested that bipolar disorder is underrecognized. Recommendations for improving the detection of bipolar disorder include the use of screening questionnaires. The Mood Disorders Questionnaire (MDQ) has been the most widely studied screening instrument for bipolar disorder, with nearly two dozen published reports on its performance. We reviewed the literature on the MDQ's performance to assess its utility as a screening instrument. METHODS: We conducted a Medline search on the terms Mood Disorders Questionnaire, MDQ, screening AND bipolar disorder, and recognition AND bipolar disorder. Only studies of adults were included. RESULTS: Across all studies the sensitivity of the MDQ was 61.3%; specificity, 87.5%; positive predictive value, 58.0%; and negative predictive value, 88.9%. Compared to the studies using the MDQ for psychiatric outpatients, studies using it in the general population found it to have much lower sensitivity and positive predictive value, and higher specificity and negative predictive value. The MDQ's sensitivity was higher in detecting bipolar I disorder than bipolar II disorder (66.3% vs. 38.6%). Lowering the threshold to identify cases markedly improved the MDQ's sensitivity, with only a modest reduction in specificity. Studies of the best symptom cutoff to identify cases have produced inconsistent findings. CONCLUSIONS: The MDQ's performance depends upon the setting in which it is used, the threshold to identify caseness, and the subtype of bipolar disorder examined. Conceptual issues in the use of a bipolar disorder screening questionnaire are discussed, and questions are raised about the clinical value of a self-report screening scale for bipolar disorder. Based on current available evidence, routine clinical use of the MDQ cannot be recommended because of the absence of studies simultaneously examining both the potential benefits (e.g., improved detection) and costs (e.g., overdiagnosis) of screening.

Depressed patients' perspectives of 2 measures of outcome: the Quick Inventory of Depressive Symptomatology (QIDS) and the Remission from Depression Questionnaire (RDQ).

BACKGROUND: Current operational definitions of remission, at their root, are exclusively symptom-based and therefore limited in scope. In this report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project we examined patient acceptability of a new measure, the Remission from Depression Questionnaire (RDQ), a scale designed to capture a broader array of domains patients consider relevant to the construct of remission. Patient acceptance of the RDQ was compared with that of the Quick Inventory of Depressive Symptomatology (QIDS), the instrument used to measure outcome in the Sequenced Treatment Alternatives to Relieve Depression study. METHODS: One hundred and two depressed outpatients in ongoing treatment completed the RDQ, QIDS, and a 9-item measure of patient preference. RESULTS: Patients indicated the RDQ was a better indicator of their overall state and treatment goals. Patients judged the RDQ to be a more accurate and preferred measure to determine treatment outcome, and a more accurate indicator of remission. CONCLUSIONS: Patients considered the multifactorial RDQ a more accurate indicator of their treatment goals than a purely symptom measure such as the QIDS.

Are screening scales for bipolar disorder good enough to be used in clinical practice?

Bipolar disorder is often underdiagnosed. Recommendations for improving the detection of bipolar disorder include the use of screening questionnaires. The most widely studied screening scale is the Mood Disorders Questionnaire (MDQ). Studies of the performance of the MDQ in heterogeneous samples of psychiatric outpatients presenting for treatment have raised concerns about the adequacy of the MDQ as a screening measure because of its relatively low sensitivity. The sensitivity of a scale is not an inherent property of the instrument but depends on the threshold used to identify positive cases. Prior studies used the scoring recommendations of the developers of the MDQ to examine its performance; none examined the performance of the scale across the range of cutoff scores to determine whether a lower threshold would be more appropriate for the purposes of screening. The goal of the present study was to examine the operating characteristics of the MDQ at all cutoff scores to determine the cutoff point that would be appropriate for the purpose of screening. Seven hundred fifty-two psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM-IV, and completed the MDQ. When MDQ caseness was based only on symptom score without regard to level of impairment, the cutoff score associated with at least 90% sensitivity was 5. At this cutoff the specificity of the MDQ was 60.7%, and its positive predictive value was 22.1%. These findings indicate that when the cutoff to identify cases on the MDQ was set to achieve a desired level of sensitivity as a screening instrument most cases screening positive on the scale did not have bipolar disorder. Low positive predictive value does not support the use of the MDQ or any bipolar disorder screening scale in psychiatric clinical practice.

Diagnosing social anxiety disorder in the presence of obesity: implications for a proposed change in DSM-5.

BACKGROUND: The proposed draft of the DSM-5 from the Anxiety Disorder Workgroup recommends allowing the diagnosis of social anxiety disorder (SAD) in individuals with medical conditions, if the anxiety is considered to be excessive. Although prior research has examined diagnosing SAD in individuals with stuttering, such research has not yet been conducted in obese individuals. METHODS: This study compared demographic and clinical characteristics of obese individuals diagnosed with DSM-IV SAD (n = 135), modified SAD (clinically significant social anxiety related to weight only; n = 40), and a group of obese individuals with no history of psychiatric disorders (n = 616). All participants were seeking psychiatric clearance for bariatric surgery and completed a comprehensive diagnostic interview. RESULTS: The two social anxiety groups differed from the no disorder group on adolescent and past 5 years social functioning, and overall current functioning. Individuals with modified SAD had a later onset of their social anxiety, yet reported greater impairment in social life and distress about their social anxiety compared to the DSM-IV SAD group. CONCLUSIONS: Although both of the social anxiety groups differed from the no disorder group on social and overall functioning, there were few differences between those with DSM-IV SAD and modified SAD. This suggests that obese individuals with social anxiety related to weight only may experience comparable severity of anxiety to those with DSM-IV SAD, and supports adoption of the DSM-5 Workgroup's recommendation to change criterion H.

Impact of obesity on the psychometric properties of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for major depressive disorder.

Obesity is associated with several symptoms that are components of the diagnostic criteria for major depressive disorder (MDD). Compared with nonobese individuals, obese individuals report more fatigue, sleep disturbance, and overeating. Obesity might, therefore, impact the psychometric properties of the MDD criteria. The goal of the present report from the Rhode Island Hospital Methods to Improve Diagnostic Assessment and Services project was to examine the impact of obesity on the psychometric characteristics of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition symptom criteria for major depression. Two thousand four hundred forty-eight psychiatric outpatients were administered a semistructured diagnostic interview. We inquired about all symptoms of depression for all patients. The mean sensitivity of the 9 criteria in the nonobese and obese patients was nearly identical (74.6% vs 74.3%). The mean specificity was slightly higher in the nonobese patients (82.0% vs 79.5%). No symptom was more specific in the obese than the nonobese patients, whereas the specificity of increased appetite, increased weight, and fatigue was more than 5% lower in the obese patients. Increased appetite, increased weight, hypersomnia, and fatigue had a higher sensitivity in the obese than the nonobese patients, whereas decreased appetite, weight loss, and diminished concentration had a higher sensitivity in the nonobese than the obese patients. Thus, although there were small differences between obese and nonobese patients in the operating characteristics of some symptoms, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for MDD generally performed equally well for obese and nonobese patients.

Psychiatric diagnoses in patients who screen positive on the Mood Disorder Questionnaire: Implications for using the scale as a case-finding instrument for bipolar disorder.

Bipolar disorder is prone to being overlooked because its diagnosis is more often based on retrospective report than cross-sectional assessment. Recommendations for improving the detection of bipolar disorder include the use of screening questionnaires. The Mood Disorder Questionnaire (MDQ) is the most widely studied self-report screening scale that has been developed to improve the detection of bipolar disorder. Although developed as a screening scale, the MDQ has also been used as a case-finding measure. However, studies of the MDQ in psychiatric patients have found high false positive rates, though no study has determined the psychiatric diagnoses associated with false positive results on the MDQ. The goal of the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project was to identify the psychiatric disorders associated with increased false positive rates on the MDQ. Four hundred eighty psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM-IV (SCID) and completed the MDQ. After excluding the 52 patients diagnosed with a lifetime history of bipolar disorder we compared diagnostic frequencies in patients who did and did not screen positive on the MDQ. Based on the Hirschfeld et al. scoring guidelines of the MDQ, 15.2% (n=65) of the 428 nonbipolar patients screened positive on MDQ. Compared to patients who screened negative, the patients who screened positive were significantly more likely have a current and lifetime diagnosis of specific phobia, posttraumatic stress disorder, alcohol and drug use disorders, any eating disorder, any impulse control disorder, and attention deficit disorder. Results were similar using a less restrictive threshold to identify MDQ cases. That is, MDQ caseness was associated with significantly elevated rates of anxiety, impulse control, substance use, and attention deficit disorders. Studies using the MDQ as a stand-alone proxy for the diagnosis of bipolar disorder should consider whether the presence of these other forms of psychopathology could be responsible for differences between individuals who screen positive and negative on the scale.

A comparison of depressed patients with and without borderline personality disorder: implications for interpreting studies of the validity of the bipolar spectrum.

The nosological status of borderline personality disorder as it relates to the bipolar disorder spectrum has been controversial. Studies have supported, in part, the validity of the bipolar spectrum by demonstrating that these patients, compared to patients with nonbipolar depression, are characterized by earlier age of onset of depression, recurrent depressive episodes, comorbid anxiety and substance use disorders and increased suicidality. However, all of these factors have likewise been found to distinguish depressed patients with and without borderline personality disorder. A family history of bipolar disorder is one of the few disorder specific validators. In the present study from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compared the demographic and clinical characteristics of depressed patients with and without borderline personality disorder. We hypothesized that many of the factors used to validate the bipolar spectrum will also distinguish depressed patients with and without borderline personality disorder except, however, a family history of bipolar disorder. Two thousand nine hundred psychiatric outpatients at Rhode Island Hospital were evaluated with the Structured Clinical Interview for DSM-IV (SCID) and Structured Interview for DSM-IV Personality Disorders (SIDP-IV). Family history information regarding first-degree relatives was obtained from the patient using the Family History Research Diagnostic Criteria. One hundred and one patients with borderline personality disorder plus major depressive disorder were compared to 947 patients with major depressive disorder alone on the prevalence of bipolar disorder validators. Compared to depressed patients without borderline personality disorder, depressed patients with borderline personality disorder had a younger age of onset, more depressive episodes, a greater likelihood of experiencing atypical symptoms and had a higher prevalence of comorbid anxiety disorders, substance use disorders, and number of previous suicide attempts. The depressed patients with borderline personality disorder did not significantly differ from the patients without borderline personality disorder on morbid risk for bipolar disorder in first degree relatives. In addition, patients with a diagnosis of bipolar disorder had a significantly higher morbid risk of bipolar disorder in first degree relatives than the borderline personality disorder group. The findings indicate that many factors used to validate the bipolar spectrum are not disorder specific. These results raise questions about studies of the validity of the broad bipolar spectrum that do not assess borderline personality disorder. Our results do not support inclusion of borderline personality disorder as part of the bipolar spectrum.

Sustained unemployment in psychiatric outpatients with bipolar disorder: frequency and association with demographic variables and comorbid disorders.

OBJECTIVES: The negative impact of bipolar disorder on occupational functioning is well established. However, few studies have examined the persistence of unemployment, and no studies have examined the association between diagnostic comorbidity and sustained unemployment. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we described the amount of time unemployed in the five years before the evaluation in a large cohort of outpatients diagnosed with bipolar disorder, and determined the demographic and clinical correlates of sustained unemployment. METHODS: A total of 206 patients diagnosed with DSM-IV bipolar I or bipolar II disorder were interviewed with semi-structured interviews assessing comorbid Axis I and Axis II disorders, demographic and clinical variables. The interview included an assessment of the amount of time missed from work due to psychiatric reasons during the past five years. Persistent unemployment was defined as missing up to two years or more from work. RESULTS: Less than 20% of the patients reported not missing any time from work due to psychiatric reasons, and more than one-third missed up to two years or more from work. Prolonged unemployment was associated with increased rates of current panic disorder and a lifetime history of alcohol abuse or dependence. Patients with prolonged unemployment were older and experienced more episodes of depression. CONCLUSIONS: Most patients presenting for the treatment of bipolar disorder have missed some time from work due to psychiatric reasons, and the persistence of employment problems is considerable. Comorbid psychiatric disorders are a potentially treatable risk factor for sustained unemployment. It is therefore of public health significance to determine if current treatments are effective in bipolar disorder patients with current panic disorder, and if not, to attempt to develop treatments that are effective.

Validity of a simpler definition of major depressive disorder.

BACKGROUND: In previous reports from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we developed a briefer definition of major depressive disorder (MDD), and found high levels of agreement between the simplified and DSM-IV definitions of MDD. The goal of the present study was to examine the validity of the simpler definition of MDD. We hypothesized that compared to patients with adjustment disorder, patients with MDD would be more severely depressed, have poorer psychosocial functioning, have greater suicidal ideation at the time of the intake evaluation, and have an increased morbid risk for depression in their first-degree family members. METHODS: We compared 1,486 patients who met the symptom criteria for current MDD according to either DSM-IV or the simpler definition to 145 patients with a current diagnosis of adjustment disorder with depressed mood or depressed and anxious mood. RESULTS: The patients with MDD were more severely depressed, more likely to have missed time from work due to psychiatric reasons, reported higher levels of suicidal ideation, and had a significantly higher morbid risk for depression in their first-degree family members. Both definitions of MDD were valid. CONCLUSIONS: The simpler definition of MDD was as valid as the DSM-IV definition. This new definition offers two advantages over the DSM-IV definition-it is briefer and therefore more likely to be recalled and applied in clinical practice, and it is free of somatic symptoms thereby making it easier to apply with medically ill patients.

Performance of the Bipolar Spectrum Diagnostic Scale in psychiatric outpatients.

OBJECTIVES: Recent research has suggested that bipolar disorder, when defined to include milder variants such as bipolar II disorder and bipolar disorder not otherwise specified (NOS), is more prevalent than had been previously reported and often underrecognized. Recommendations for improving the detection of bipolar disorder have included careful clinical evaluations inquiring about a history of mania and hypomania and the use of screening questionnaires. The Bipolar Spectrum Diagnostic Scale (BSDS) was designed to be particularly sensitive to the milder variants of bipolar disorder. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined the operating characteristics of the BSDS in a large sample of psychiatric outpatients presenting for treatment. METHODS: A total of 1,100 psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM-IV and asked to complete the BSDS. Missing data on the BSDS reduced the sample size to 961, approximately 10% (n = 90) of whom were diagnosed with bipolar disorder. RESULTS: The sensitivity of the BSDS was similar for bipolar I disorder, bipolar II disorder, and bipolar disorder NOS/cyclothymia. A receiver operating curve (ROC) analysis indicated that cutoffs of 11 and 12 maximized the sum of sensitivity and specificity for the entire group of patients with bipolar disorder (area under curve = 0.80, p < 0.001). The cutoff point associated with 90% sensitivity for the entire sample of patients with bipolar disorder was 8. At this cutoff the specificity of the scale was 51.1% and positive predictive value was 16.0%. We compared the patients with and without bipolar disorder on each of the BSDS symptom items. The odds ratios were higher for the items assessing hypomanic/manic symptoms than items assessing depressive symptoms. We therefore examined the performance of a subscale composed only of the hypomania/mania items. The area under the curve in the ROC analysis was nearly identical to that of the entire scale (0.81, p < 0.001). CONCLUSIONS: With its high negative predictive value, the BSDS was excellent at ruling out a diagnosis of bipolar disorder; however, the low positive predictive value indicates that it is not good at ruling in the diagnosis. These data raise questions about the use of the BSDS as a screening measure in routine clinical psychiatric practice.

A different approach toward screening for bipolar disorder: the prototype matching method.

Most screening scales for psychiatric disorders consist of a series of questions about the signs and symptoms of the disorder of interest, and to determine whether a patient screens positive, the scores of the individual items are summed and the total score is compared with an empirically derived threshold. A problem with the score summation approach toward case identification on screening scales is that different studies may find that different thresholds are optimal for distinguishing cases from noncases. An alternative approach toward screening is the prototype matching approach, in which respondents are asked to indicate how well their clinical history matches the described prototype. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we compared the symptom summation and prototype matching approaches toward screening for bipolar disorder in a large sample of psychiatric outpatients. Nine hundred sixty-one psychiatric outpatients were interviewed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition and completed the Bipolar Spectrum Disorders Scale (BSDS). The BSDS is a unique screening scale consisting of a prototypic description of bipolar disorder. The respondent checks off which items in the prototypic paragraph describes them and also answers a single multiple-choice question at the end of the paragraph asking how well the paragraph describes them. The results of a receiver operating curve analysis found that the score summation and prototype matching approaches toward screening on the BSDS performed equally well. These findings provide preliminary evidence that an alternative approach toward psychiatric screening, the prototype matching approach, is as effective as the traditional score summation method. This raises the intriguing possibility of developing a combined screening scale/educational instrument that can be formatted as a brochure and thus placed in clinicians' waiting rooms, thereby facilitating use of the measure.

Overdiagnosis of bipolar disorder and disability payments.

The diagnosis of bipolar disorder has received increasing attention during the past decade. Several research reports have suggested that bipolar disorder is under-recognized, and that many patients, particularly those with major depressive disorder, have, in fact, bipolar disorder. More recently, some reports have suggested that bipolar disorder is also overdiagnosed at times. There are several possible reasons for bipolar disorder overdiagnosis. In the present study, we examined whether secondary gain associated with receiving disability payments might be partially responsible for bipolar disorder overdiagnosis. A total of 82 psychiatric outpatients reported having been previously diagnosed with bipolar disorder, which was not confirmed when interviewed with the Structured Clinical Interview for DSM-IV. The percentage of patients receiving disability payments and the duration of disability payments were compared in these 82 patients and 528 patients who were not diagnosed with bipolar disorder. Compared with the patients who had never been diagnosed with bipolar disorder, the patients overdiagnosed with bipolar disorder were significantly more likely to have received disability payments at some point during the past 5 years, and were receiving disability payments for significantly more weeks. We conducted a regression analysis controlling for the number of lifetime diagnoses, and overdiagnosis of bipolar disorder was a significant predictor of disability status (OR = 3.8; 95% CI, 1.6-8.8). Thus, an unconfirmed diagnosis of bipolar disorder was significantly associated with receiving disability benefits.

Recognition of irrationality of fear and the diagnosis of social anxiety disorder and specific phobia in adults: implications for criteria revision in DSM-5.

BACKGROUND: In DSM-IV, the diagnosis of social anxiety disorder (SAD) and specific phobia in adults requires that the person recognize that his or her fear of the phobic situation is excessive or unreasonable (criterion C). The DSM-5 Anxiety Disorders Work Group has proposed replacing this criterion because some patients with clinically significant phobic fears do not recognize the irrationality of their fears. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project we determined the number of individuals who were not diagnosed with SAD and specific phobia because they did not recognize the excessiveness or irrationality of their fear. METHODS: We interviewed 3,000 psychiatric outpatients and 1,800 candidates for bariatric surgery with a modified version of the Structured Clinical Interview for DSM-IV. In the SAD and specific phobia modules we suspended the skip-out that curtails the modules if criterion C is not met. Patients who met all DSM-IV criteria for SAD or specific phobia except criterion C were considered to have "modified" SAD or specific phobia. RESULTS: The lifetime rates of DSM-IV SAD and specific phobia were 30.5 and 11.8% in psychiatric patients and 11.7 and 10.2% in bariatric surgery candidates, respectively. Less than 1% of the patients in both samples were diagnosed with modified SAD or specific phobia. CONCLUSION: Few patients were excluded from a phobia diagnosis because of criterion C. We suggest that in DSM-5 this criterion be eliminated from the SAD and specific phobia criteria sets.